Outreach Request Form

If you are interested in a having the Counseling Center provide a virtual workshop or program, please complete the Outreach Request Form below. Someone from our office will review your request and contact you, typically within 3-5 days of your initial request. If you need assistance or have any questions about using this form, please contact the Counseling Center.

We ask that all programming requests be submitted at least three weeks before the program date to allow us enough time to identify facilitators and tailor programming to meet your individual needs. If you have an urgent request (e.g., death in UIC community, responding to current events), please contact the Counseling Center directly at 312-996-3490.

While we make every effort to meet requests, please note that certain peak times of the year do not allow us the resources to meet all requests. If this is the case, we will be happy to recommend other resources or discuss another time of the year when we might be able to collaborate.

Disclaimer Heading link

Please note that this form is only to be used to request an outreach program or workshop. This form is not confidential and should not be used to communicate any potentially sensitivity information. If you are a student looking for support for a mental health concern, please see our Services page for appropriate resources.

Check Out Our Common Program Topics

Outreach Request Form Heading link

Contact Information
Please provide your contact information, or the information for the individual responsible for coordinating this program with the Counseling Center.
Name * Required
First Last
Role * Required
Phone Number
Email Address * Required
Program Details
Please indicate your preferred dates, times, and format of the program. We ask that all programming requests be submitted at least three weeks before the program date to allow us enough time to identify facilitators and tailor programming to meet your individual needs. If you have an urgent request (e.g., death in UIC community, responding to current events), please contact the Counseling Center directly at 312-996-3490.
Event Format * Required
For Fall 2023, we can provide outreach services virtually via Zoom, and pending availability, in person. How should our Counseling Center representative join you for your event?
- Virtually
- In-Person
- Either Virtually or In-Person
Preferred Date for Program (First Choice) * Required
MM slash DD slash YYYY
Expected Start Time (First Choice) * Required

Hours :

Minutes

AM/PM AM/PM
Preferred Date for Program (Second Choice) * Required
MM slash DD slash YYYY
Expected Start Time (Second Choice) * Required

Hours :

Minutes

AM/PM AM/PM
Preferred Date for Program (Third Choice) * Required
MM slash DD slash YYYY
Expected Start Time (Third Choice) * Required

Hours :

Minutes

AM/PM AM/PM
Duration of the Program * Required
Please note that most of our programs are designed to be about 45-50 minutes. We are usually able to best accommodate programs that are one hour or less in duration.
If you would like to provide more information about the date, time, or duration of the program, please do so here
Estimated number of people who will attend * Required
Unless a specific exception is made, we ask that each program has at least 10 participants.
Location
For virtual programs, please specify if using software other than Zoom.
Program Content
Please describe the type of program you are requesting.
What type of program are you requesting? * Required
See the Request a Program page at counseling.uic.edu/outreach-consultation/request-program for a description of common programs.
If other, please specify:
Are there particular topics you want to make sure we address in this program?
Who is this program for? * Required
e.g., organization, class, office
Will any known participants require accommodations to make this program more accessible? * Required
e.g., printed slides, closed captions, interpreter
What prompted you to request this program? * Required
Do you have any additional requests or other information that may be helpful?
- I am a Counseling Center staff member completing this form on behalf of someone else
If you are a Counseling Center staff member completing this form on behalf of someone else, please write your name here:
Comments
This field is for validation purposes and should be left unchanged.